Healthcare Provider Details

I. General information

NPI: 1831784883
Provider Name (Legal Business Name): REYNOLDS ORAL & MAXILLOFACIAL SURGERY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 02/11/2022
Certification Date: 12/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 VINE ST
PRINCETON WV
24740-3931
US

IV. Provider business mailing address

104 VINE ST
PRINCETON WV
24740-3931
US

V. Phone/Fax

Practice location:
  • Phone: 304-250-1214
  • Fax: 681-282-5792
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: KRISTOPHER REYNOLDS
Title or Position: OWNER
Credential:
Phone: 304-250-1214